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General NPI Number Information
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NPI Number | 1972540854
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Entity Type | Organization
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Legal Business Name | ASSOC. OF MAPLE PODIATRY,PA
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Dates
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Enumeration Date | 06/01/2006
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Last Update Date | 07/01/2009
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Provider Practice Location Address
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Address Line | 702 W MAPLE AVE
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City | MERCHANTVILLE
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State | NJ
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Zip | 08109-1822
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Country | US
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Telephone | 856-665-1180
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Fax | 856-665-5537
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Provider Business Mailing Address
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Address Line | 702 W MAPLE AVE
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City | MERCHANTVILLE
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State | NJ
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Zip | 08109-1822
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Country | US
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Telephone | 856-665-1180
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Fax | 856-665-5537
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHN A WALLACE
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Credential | DPM
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Telephone | 856-665-1180
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | MD00151900
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License Number State | NJ
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